Volume 36 Number 1
Fall 1996

SUICIDE AMONG AMERICAN INDIAN YOUTH: THE ROLE OF THE SCHOOLS IN
PREVENTION

Arlene Metha and L. Dean Webb

Since the highest suicide rates are found among American
Indian youth, the schools must assume a major role in suicide prevention.
Suicide risk factors are discussed for the general adolescent population
as well as for American Indian youth. School-based programs are described
in terms of prevention, intervention, and postvention activities with
an emphasis on adaptation to specific tribes and customs.

The Problem

Every one hour and 46 minutes somewhere in the United States
one young person takes his or her life. Suicide is now the third leading
cause of death of 15-24 year olds in the United States (Centers for
Disease Control, 1995). Every year almost 5,000 young people aged 10-24
years old take their own lives (CDC, 1995). Of these, the highest suicide
rates are found among American Indian youth (see Table 1). Not only
do young American Indian males commit suicide at rates almost twice
that of other racial groups, the rates increase with age far more dramatically
than those of other groups. It should be noted, however, that suicide
rates do vary widely among the various tribes, ranging from 6 per 100,000
among the Chippewa, to 130 per 100,000 among the Blackfeet (Group for
the Advancement of Psychiatry (GAP) as cited in Lipschitz, 1995).

As alarming as are the statistics on completed suicides, evidence suggests
that the number of actual suicides may in fact be far greater than the
number reported. The social, cultural, or religious stigma attached
to suicide, the belief that insurance might be forfeited, and the difficulty
in determining whether some accidents (e.g., pedestrian deaths, vehicular
deaths, and barbiturate poisonings) are actually accidents or suicides,
and the desire to avoid publicity have resulted in both the intentional
and the unintentional under-reporting of suicides. Estimates of the
under-reporting have been as high as 80 percent (Phillips & Ruth,
1993).

While the number of youth suicides is in itself of such a magnitude
as to create a major national health concern, this concern is compounded
by the evidence that for every completed suicide there are as many as
20 (Washington State Department of Health, 1995) to 50-100 attempts
(Spirito, Hart, Overholser, & Halverson, 1990). Grossman, Milligan,
and Deyo (1991) analyzed data from the 1988 Navajo Adolescent Health
Survey of 7,254 students grades 6 through 12 on the Navajo reservation
and found that 971 students (15 percent) had attempted suicide. A higher
incidence (23 percent) was reported by Manson, Beals, Dick and Duclos
(1989) in their study involving American Indian students attending a
boarding school in the southeastern United States. Yet an even higher
rate of suicide attempt (30 percent), a rate significantly higher than
that for youth in the general population, was found by Howard-Pitney,
LaFromboise, Basil, September, and Johnson (1992) among Zuni adolescents
at a pueblo in New Mexico. In addition, Gartrell, Jarvis and Derksen
(1993) reported that seven percent of the 12 and 13 year old Alberta
Indians in their study had attempted suicide, as had 16 percent of the
14 year olds, and 25 percent of those over 15 years of age.

Table 1Suicide Rates for Youth 10-24 Years of Age, by Race and Ethnicity: 1990
(Rates in suicides per 100,000)

Native American

White

Black

Hispanic

Asian

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Age:

10-14 yrs.

6

1.0

2.3

.9

1.6

.6

1.0

1.1

.7

.4

15-19 yrs

36.4

6.5

19.3

4.0

11.5

1.9

10.9

3.2

12.0

4.0

20-24 yrs

62.6

5.8

26.8

4.4

19.0

2.6

17.8

3.1

14.0

3.8

Source: Centers for Disease Control (CDC) (1995).
Suicide in the United States 1980-1992. Atlanta, GA: Author.

The research on risk factors associated with American Indian youth
indicates that many of those same variables place them at risk for suicidal
behavior. For example, Grossman et al. (1991) found a history of mental
health problems, family history of a suicide or suicide attempt, weekly
consumptions of hard liquor, past physical or sexual abuse, alienation
from family and community, and poor self-perception of health to be
risk factors for suicide attempt among Navajo youth. Manson et al. (1989)
found the risk factors for suicide among American Indian students at
a boarding school to be having either relatives or friends who have
attempted suicide, greater depressive symptomatology, greater quantity
and frequency of alcohol use, and little family support. Manson et al.
(1989) also summarized the literature on suicide among American Indian
and Alaska Natives identifying the following risk factors: frequent
interpersonal conflicts; prolonged, unresolved grief, chronic familial
instability; depression; alcohol abuse and dependence; family history
of psychiatric disorder-particularly alcoholism, depression and suicide;
physical illness; previous suicide attempt; frequent encounters with
the criminal justice system; and multiple home placements.

The research of Howard-Pitney et al. (1992) investigated the psychosocial
variables that might impact suicide ideation and suicide attempt among
Zuni adolescents. Correlates of suicide ideation were found to be drug
use, depression, hopelessness, stressful life events and psychological
distress. Correlates of suicide attempt included the same variables,
as well as suicide ideation and poor coping skills. On the other hand,
social support, a positive attitude toward school, and good communication
skills were negatively correlated with suicide ideation, and a positive
attitude toward school and good communication skills were negatively
related to suicide attempt. Lastly, Gartrell et al.'s (1993) study of
seventh, eighth, and ninth graders on seven reserves in Alberta reported
elevated levels of suicide ideation for American Indian adolescents
with low psychological wellbeing, no father in the household, and a
history of suicide in the household. Risk factors for suicide attempt
were low psychological well-being, heavy alcohol use, and no father
in the household.

One set of suicidal risk factors that are somewhat unique to American
Indians focus on the stressors they experience as a result of social
disintegration and cultural conflict (Berlin, 1985; Hochkirchen &
Jilek, 1985). As with other risk factors, these risk factors have a
differential impact among tribes. As Lipschitz (1995, citing the GAP)
explains:

Lower suicide rates are found to prevail in tribes
like the Navajo, who have succeeded in maintaining a separatist cultural
identity, and in those like the Cree, who have evolved a cultural, economic,
and political integration with the dominant society over the course
of their long period of contact. Both forms of adaptation allow these
tribes to provide a supportive milieu that sustains identity consolidation
in their young people. In other groups the separatist and integrationist
paths have failed to prevent the disruption of cultural values. Concurrently,
members of these marginalized groups have not been able to adopt values
from the prevailing American culture in ways that preserve their social
pride and personal self-esteem. The social alienation, identity confusion,
and self-hate that they experience are reflected in their high rates
of alcoholism and suicide. (p. 163)

And, as LaFromboise and Bigfoot (1988) so pointedly note, for many
American Indians "'whose lives have been affected by the governmental
goal of assimilating them into the general ethos of American life, suicide
could be construed as the ultimate act of freedom" (p. 139). The
researchers also note that the identity conflict or ambiguity has perhaps
its most profound impact as the American Indian child enters adolescence,
a developmental stage that in almost all children is characterized by
varying degrees of psychological turmoil, and that the negative life
stressors which have been found to place all youth at risk for suicide-loss
of a family member by death or separation, long-term poverty, parental
unemployment, and underachievement in school-are far more prevalent
in the lives of American Indian youth than those in the larger society.

LaFromboise and Bigfoot (1988) also discuss specific cultural values
and beliefs that may contribute to suicidal behavior among American
Indian youth. For example, the cultural value placed upon self-control
often results in American Indian youth both internalizing psychological
pain, and the feeling that death is not to be feared but is an active
process where the individual can exercise control over the preparation
for death. The values of social responsibility and reciprocity may also
contribute to imitative behavior, while the idealization of the deceased,
including those who have committed suicide, during giveaway ceremonies
may tempt others to join the deceased and be similarly honored. American
Indian beliefs in reincarnation and the reciprocity of influence between
the human and spirit worlds serve as an interpretive system when deciding
whether or not to self-destruct and may reduce some of the fear surrounding
death.

School-Based Prevention

While prevention of the needless death of so many of our young people
is the responsibility of the entire community, it is without question
that the schools must assume a major role in the suicide prevention
efforts of the community. The assumption of this role seems particularly
incumbent upon those schools which serve American Indian youth. Few
others have the opportunity of school personnel to interact daily with
young people and to observe the changes in their behavior, to understand
the stressful situations they encounter, or to respond to their subtle
or direct cries for help (Smith, 199 1).

Suicide prevention is often discussed in terms of three levels or domains.
Some typologies refer to primary, secondary, and tertiary prevention;
others prevention, intervention, and postvention.

Prevention
Whatever the title, normally the first level of prevention in a school-based
prevention program involves raising the awareness of students, parents,
and the school staff about the problem of youth suicide and the behavioral
signs, physical symptoms, and stress indicators typically associated
with youth at risk for suicide, and providing them information about
community mental health resources and referral procedures.

For students this information is often included as part of a general
health curriculum and will typically include additional material on
how to respond to a a troubled peer. While this type of curriculum is
not targeted to students at any a specific level of suicide risk or
to any particular risk factors, having even this brief overview can
be a matter of life or death to many troubled youth. Because adolescents
have little experience with life and few well-developed coping skills,
they do not realize that their feelings of depression are usually limited
in duration and a are not a sign of inadequacy. And, because a peer
is the most common confidant of a suicidal youth, they need to know
how to recognize suicide warning signs a and where and how to get professional
assistance for a troubled peer. They also need to understand the myths
and misconceptions about suicide, to take warnings signs seriously,
and to break a confidence to save a life (Ryerson, 1991).

Parents also desperately need this information. According to one expert
on youth suicide, "(P)arents are often inexperienced with or ignorant
about the emotional difficulties of adolescents. Reluctant to acknowledge
emotional difficulies ties in their own child, they frequently deny
the seriousness of a teenager's despair until it is too late" (Ryerson,
1991, pp. 100-101). While it is often difficult to reach and obtain
the participation of parents or guardians at suicide awareness sessions,
aggressive outreach programs involving phone chains, using community
leaders as speakers, and even raffles have been used with varying degrees
of success I (Ryerson, 1991). These and any other strategies that offer
the potential to increase family involvement should be used to remind
parents and guardians that their children's lives are at risk.

Training for faculty and staff should be mandatory and should be provided
[(to all those adults who come in contact with students, including custodial,
secretarial, and transportation staff. Such training can last from two
hours to two days. However, a common practice is to provide a one day
in-service for the entire faculty and staff, and a second day for those
who are to serve on the school or ;(school district crisis response
team (discussed below). It should be emphasized -1 that the purpose
of this training is not to train faculty or staff to provide counseling
or risk-assessment services; these services should only be provided
by per;(sons with expertise in these areas (Capuzzi, 1994).

Intervention
Because of the high incidence of suicide among American Indian youth,
it has been suggested by several researchers that the schools which
serve these youth should focus their prevention efforts on the next
level of prevention, that which seeks to identify those youth most at
risk and to target programming toward the modification of those conditions
which make them vulnerable to or protect them against suicide (Grossman
et a]., 199 1; LaFromboise & Howard-Pitney, 1995). These programs
address what are presumed to be the antecedent conditions of suicide
(as well as other at risk behaviors), and make no mention of suicide
in their titles (Felner, Adan, & Silverman, 1992). They include
life-skills programs, decision-making skills programs, self-esteem building,
stress reduction, socialskills training, anger and aggression management,
coping skills programs, and problem-solving skills training.

However, before any students are involved in these intervention programs,
the necessary first step is the identification of those at greatest
risk for suicide. This can be accomplished in several ways. As already
noted, all school staff should be trained to recognize the warning signs
of suicide. If a staff member does have concerns about a youth that
might be at risk for suicidal behavior, the staff member should express
his or her concern to the student (do not be afraid to ask the student
directly if he or she has entertained thoughts of suicide), attempt
to establish rapport with the student, and facilitate a meeting with
the school counselor or a crisis team member as quickly as possible
(Capuzzi, 1994).

Identification of youth at risk for suicide can also be accomplished
by a formal multistage process to determine the level of risk. The first
step would involve the administration of a short instrument, such as
the Suicide Ideation Questionnaire (Reynolds, 1988), to identify those
at risk for suicide. Students found to be at high risk should then be
referred for additional assessment using a more intensive instrument
such as the Evaluation of Imminent Danger for Suicide (Bradley &
Rotheram-Borus, 1990) or the Measurement of Adolescent Potential for
Suicide (Eggert, Thompson, & Herting, 1994), which are administered
in a face to face interview by a trained counselor, psychologist, psychosocial
nurse specialist, or other mental health professional. Those identified
as being at imminent danger for suicide should be referred for additional
evaluation and intervention by mental health professionals. Those not
requiring emergency intervention should be provided the appropriate
counseling intervention.

As suggested previously, intervention programs can be directed at the
treatment of specified risk factors (e.g., substance abuse prevention
or depression management), the development of specific skills (e.g.,
problem-solving skills, decision-making skills, or coping skills), or
the enhancement of protective factors [e.g., family cohesion, positive
school experience, or positive friendships (Rubenstein, Heeren, Housman,
Rubin, & Stechler, 1989)]. One such program, a life/social skills
training program developed by LaFromboise and Howard-Pitney (1995) for
use with Zuni high school students shows promise for use with other
populations of American Indian youth. Life/social skills training programs
are intended to teach the social competencies and fife skills needed
to support positive social, emotional and academic development. The
curriculum employed with the Zuni students included 7 major units: self-esteem
building, identifying emotions and stressors, communication and problem-solving
skills training, recognizing and eliminating self-destructive behavior,
suicide information, suicide intervention, and personal and community
goal setting. The curriculum was presented three times a week throughout
the year (over 30 weeks). According to the developers, each lesson included
"the standard skills training techniques of providing information
about the helpful or harmful effects of certain behaviors, modeling
of target skills, experimental activities and behavioral rehearsal for
skill acquisition, and feedback for skill refinement" (LaFromboise
& Howard-Pitney, 1995, p. 48 1). The life/social skills training
was found to be effective in reducing hopelessness and suicide probability
as well as improving anger management, and problem-solving.

The curriculum was designed to be compatible with the norms of Zuni
tradition including its values, beliefs, and attitudes; sense of self,
space, and time; communication styles; and forms of recognition. Extensive
community input was sought during the development of the curriculum.

Postvention
Postvention programs attempt to respond to the emotional and psychological
impact of a suicide on those remaining. The goal of postvention is to
support faculty, staff, and students with the grieving process and to
prevent further suicides. The postvention program should be developed
and in place in every school before a suicide has occurred, not after.

The first step in postvention is the appointment of a crisis management
team, typically composed of the principal or assistant principal, guidance
counselors, the school nurse, classroom teachers, and the school psychologist.
The role of the crisis management team is to develop and put in place
the actions and activities that follow the suicide of a student. The
typical postvention program would proceed as follows (Cappuzi, 1994;
Wenckstem & Leenaars, 1991):

(1) Verify any report of a suicide with the police department or medical
examiner. If confirmed, notify central administration.
(2) Inform faculty and staff of the suicide. Ideally such information
should be given at a meeting of the entire faculty and staff. If this
is not possible, then faculty and staff should be telephoned or notified
by a member of the crisis team who would go to each classroom or office
to inform teachers/staff. Every effort should be made to prepare teachers
to assist students before any engagement of students. It is also critical
that the reactions of staff to the suicide be addressed before the staff
can be expected to assist students.
(3) Inform, individually and in person, close friends or relatives of
the victim.
(4) Contact the victim's family to offer condolences and support. Inform
them of the planned postvention efforts and, if possible, obtain the
family's assistance in identifying friends or relatives in other schools
who may need assistance.
(5) Prepare a written statement. Such a statement, should provide the
facts of the suicide without any detailed description, a recognition
of the sorrow and distress the death will cause, and information about
resources available to help students with their grief or other emotions.
If possible, this information should be transmitted on a class by class
basis by members of the crisis response team ,or by a member of the
team paired with a teacher. Opportunity must also be provided for students
to share their feelings in the supportive environment of a small group
(6) Respond to inquiries from the community. It is important that a
system be in place to handle inquiries from the media, parents, and
the larger community. One member of the administration or mental health
staff should be designated as the official spokesperson. However, all
staff, and especially school secretaries who are often the point of
first contact, should be briefed on how appropriately respond to inquiries.
While school personnel need to respond accurately and professionally
to all inquiries, the school should avoid becoming the principal source
of information. It should be made clear that releasing details about
the suicide is the responsibility of the medical examiner or other authority.
In responding to any inquiries an explanation should be made of the
efforts being made to help students deal with the tragedy, as well as
information provided about where troubled youth or their families can
obtain assistance.
(7) Communicate with parents. A letter should be sent to the parents
of classmates of the victim providing them with information about the
suicide, alerting them to be sensitive to their child's response, and
encouraging them to contact the school if they have any personal concerns
or observe any behavioral changes in their child.
(8) Provide counseling services. Prevention in the postvention context
includes individual and group counseling for those most impacted by
the suicide, as well as those who may be at increased risk because of
the suicide. Postvention prevention may also include the provision of
additional suicide awareness/prevention workshops for school staff,
students, and parents. However, such training should not be instituted
until after the initial phase of the crisis is past.
(9) Provide follow-up consultation. Approximately two to three months
after the suicide the suicide prevention team should hold a meeting
to assess the effectiveness of postvention efforts and, as necessary,
to revise the program for the future. Provisions should also be made
to insure that follow-up counseling and outreach initiatives continue
as long as needed.

Conclusion

School-based suicide prevention programs that are shaped and designed
to be compatible with local American Indian norms, values and traditions
are sorely needed. All prevention efforts should be comprehensive and
should include a wide variety of input from the community and families.
Where appropriate, adaptation to specific tribes and customs should
be made.

Each time a young person takes his or her life it dramatically affects
the lives of at least six to eight other significant individuals-with
sometimes permanent consequences to productivity, self-esteem, or physical
or mental health (Maris & Silverman, 1995).

However, the real tragedy of youth suicide is not in the suffering
and pain felt by the survivors, but in the fact that it is a needless
waste of human potential, of a life that will never be realized. Suicide
is typically not the result of a single event. It is the end in a series
of events, emotions, and beliefs that have placed the individual at
risk for suicide. But youth suicide does not have to happen. People
and institutions can play a vital role in altering the individual's
perception of those events, emotions, and beliefs. Schools, in particular,
are in a strategic position to intervene and help at a variety of levels.

Arlene Metha, Ph.D., is a psychologist and professor
of Counseling Psychology at Arizona State University. She has published
widely in the area of adolescent suicide, in particular school-based
suicide prevention and the predictors of suicide risk. She is currently
directing the Institute for the Study and Treatment of Adolescents At
Risk for the College of Education at Arizona State University.

L. Dean Webb, Ph.D., is a professor of Educational
Leadership and Policy Studies at Arizona State University. Her expertise
is in the areas of school finance, school law, and educational foundations.
Fortner Dean of the College of Education at Arizona State University,
she is the author or coauthor of ten books and numerous articles on
school administration and foundations of education.

Correspondence concerning this article should be sent to Dr. Arlene Metha, Division of Psychology in Education, Arizona State University, Tempe, AZ 85287-0611

Ryerson, D. (1991). Suicide awareness in schools: The
development of a core program and subsequent modifications for special
populations or institutions. In A. A. Leenaars & S. Wenckstem, S.(
Eds.), Suicide prevention in schools (pp. 99-120). New York:
Hemisphere Publishing.